In the United States, medical insurance plans operate under a gatekeeper concept. This is a system under which a member must select a primary care physician (PCP) who then provides or authorizes all care for that particular member. Any member needing to see a specialist provider, such as a cardiologist or dermatologist, must first obtain a medical referral from the PCP. A failure to comply with this requirement generally results in a denial of coverage for the specialist visit. In most instances, the member (hereinafter referred to as the “patient”) cannot schedule an appointment with the specialist without an authorized and approved referral request.
The PCP is usually a general practitioner, and she is responsible for determining whether the patient requires the specialist. As a result, the PCP must either perform her own office examination of the patient, or at least review the patient's medical records before issuing the referral request. The PCP then sends a referral request to the patient's insurance company for approval. If the insurance company approves the referral request, then the PCP mails this approved referral request to the specialist's office. All of the above transactions must transpire before the patient can schedule an appointment with the specialist. A significant lapse in time can exist between the patient's initial need and when the patient actually visits the specialist.
The passage of the Health Insurance Portability and Accountability Act (HIPAA) by Congress in 1996 has further complicated the referral request system. HIPAA establishes rigorous standards for protecting sensitive patient information. Health care providers are legally liable for maintaining these strict standards. As a result, many medical offices no longer fax or e-mail referral requests. Instead, they mail hard-copies of the referrals to the recipient offices, and then confirm receipt with telephone calls. Aside from generating a tremendous amount of paperwork, such transactions also contribute to loss of time, decrease in efficiency and productivity, and increased financial burdens on health care providers. Moreover, constant mailing of documents between the various offices invariably results in information that is lost in transaction.
In addition, the initial referral request does not provide unlimited visits to the specialist. If the patient requires additional visits to the specialist which are not listed in the original referral request, she must submit a new treatment plan to her PCP. Thus, the patient bears the burden of continually inquiring about the status of her referral (e.g. whether the time frame has expired or number of visits been exceeded) whenever she schedules another appointment with the specialist office.